Ethical issues in couseling
Ethical issues in counseling are ever present as the therapeutic relationship is one of the most complicated in all the helping professions. Ethical guidelines are implemented to help the therapist avoid possible pitfalls and provide a suitable level of care. Each governing body for the different therapist professions (i.e., psychologists, counselors, social workers, etc.) has its own set of ethics codes, but, as you might imagine, they are quite similar. Here are some of the essential ethical issues in counseling.
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Ethical issues in counseling
Ethical issues in counseling typically fall into five categories.
Boundaries
Boundaries are one of the most crucial ethical issues in counseling.
Therapists must create firm boundaries with their clients to prevent dual relationships. Here are some of the most common boundary issues that arise in therapy:
- Self-disclosure: Therapists must be careful not to disclose too much information about themselves to clients. They must remember that therapy is about the client, and too much self-disclosure crosses the line of professionalism.
- Physical relationships: Physical intimacy of any kind is not allowed with clients in therapy. Not only does it exploit the power differential between therapist and client, it will completely ruin the therapeutic relationship and render therapy useless.
- Friendships: Developing a friendship with a client is similarly frowned upon. While friendships may be more subtle than a sexual relationship, they still disrupt the objectivity and focus of therapy. As such, therapists are not allowed to accept large gifts from clients because it blurs the line between professional and personal. Therapists also do not want to accept a client who may know someone in their social circle.
- Other dual relationships: Therapists must be highly conscious about engaging with clients outside of the therapeutic relationship. Some areas of difficulty might include business relationships, contacts on social media, and encountering someone regularly in your community.
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Confidentiality
Confidentiality is another huge ethical issue in counseling. Clients only feel comfortable sharing information if they trust the therapist to keep it private.
The following are confidentiality issues raised in psychotherapy:
- Informed consent: Clients have a right to know about every aspect of their therapy experience and must be provided an opportunity to consent. This includes the limits of confidentiality, the cost of therapy, and the course of treatment. Therapists must share with clients instances where confidentiality can be broken for episodes of abuse, neglect, and self/other harm.
- Record keeping: Clients need to be informed about how you store their medical records and who may have access to them. Practice management software and online therapy bring about a host of new concerns with electronic record-keeping. For example, is your record keeping system HIPAA compliant? Will office staff (if you have any) be able to see the information? Therapy records contain a lot of sensitive information. They need to be kept highly secure.
- Release of information: Clients also need to know what third parties could obtain information about their therapy and exactly what will be shared. For example, if a client uses insurance, what will be shown to the insurance company? Or, if a client signs a release of information to another party, will the therapist be able to share any information they want? Client information is often shared with others. Clients must be made aware of and approve the extent of this information sharing.
Competence
Therapist competence is an ethical issue in counseling that frequently slides under the radar. Clients implicitly trust that their therapist knows what they are doing. But that isn’t always the case. Here are a few competence issues that therapists need to observe to prevent ethical breaches.
- Scope of practice: No therapist is an expert in treating every type of problem. Therapists have specific training and experiences with certain types of issues. Even therapists who see a wide variety of diagnoses have areas they don’t know much about. It is the ethical obligation of the therapist to only see clients where they feel they are competent to treat them.
For example, a therapist may be given a referral for a woman with anorexia but they have no specialized experience in treating eating disorders. Or, the client may be looking for cognitive-behavioral therapy but the therapist has a background as a psychoanalyst. No therapist wants to turn down business but it is more important that they don’t treat someone outside their scope of practice.
- Cultural sensitivity: Similarly, therapists may not be qualified to treat certain groups of people. For example, say you have a potential client that is Latino and transgender. Are you familiar with the Latino culture? Have you treated transgender people before? Unless you have specialized training or experience with those populations, they may be better served seeing someone who understands their issues better.
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Billing and insurance
Billing is often at the forefront of ethical issues in counseling.
Here are some of the areas which require the most attention:
- Inaccurate billing: Money is no laughing matter. Nothing can sabotage the therapeutic relationship quicker than inaccurate billing. You may have someone who handles your billing but you are ultimately responsible. Double-check that it is correct before you charge your client.
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- Over charging: When insurance is footing the bill, it may be tempting to charge for sessions and services that never happened. After all, it is not the client that has to pay. Don’t do it. This is unethical and considered fraud.
- Diagnostic exaggeration: Some mental health conditions aren’t covered by many insurance plans (e.g., personality disorders). So, what do you do when your client needs therapy but their insurance won’t pay for it? Or, a client wants you to write a letter saying they need medication or have a disability when you disagree? You may feel like you are helping your client, but lying about a diagnosis to get your clients covered by insurance or disability is a big ethical no-no.
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Termination
Termination can be a tricky subject for any therapist but there are a couple of ethical concerns of which therapists need to be aware.
- Delaying the end of therapy: If a client has achieved their goals or you find yourself spinning your wheels it may be time to terminate therapy. However, many therapists won’t end therapy unless the client explicitly states that they want to terminate. It is the duty of the therapist to bring up termination if they believe that the client will no longer benefit from continued sessions.
- Client abandonment: Some clients are difficult and you may feel some dread about seeing them. However, that is not an ethical reason for ending therapy. Unless the client will be harmed or receive no benefit from continuing therapy, you are obligated to continue to provide them with services. For clients that you feel like you can no longer work with, a reasonable referral to another provider is required.
Conducting psychotherapy can be a minefield of ethical concerns. Therapists’ ethical principles are crucial to maintaining the highest level of care and safety for their clients and the community.
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Ethics codes according to profession
Therapists have different educational backgrounds. Some are social workers, others are psychologists, many are professional counselors. The following are links to the ethics codes for different governing bodies of therapists.
- American Psychological Association
- National Board for Certified Counselors
- American Counseling Association
- American Mental Health Counselors Association
- National Association of Social Workers
- American Association for Marriage and Family Therapy (AAMFT)
Resources
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More resources
- Therapy resources and worksheets
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- Insurance billing 101
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- 9 Admin tasks to automate in your private practice
References
American Psychological Association. (2018). APA adopts new multicultural guidelines. Monitor on Psychology, 49(1). https://www.apa.org/monitor/2018/01/multicultural-guidelines
Barnett, J.E. (n.d.) Society for the Advancement of Psychotherapy. Informed consent in clinical practice. https://societyforpsychotherapy.org/informed-consent-in-clinical-practice-the-basics-and-beyond/
Healthcare Compliance Pros. What does being HIPAA compliant really mean?https://www.healthcarecompliancepros.com/blog/what-does-being-hipaa-compliant-really-mean
Smith, D. (2003). 10 ways practitioners can avoid frequent ethical pitfalls. Monitor on Psychology, 34(1). https://www.apa.org/monitor/jan03/10ways
Stoll, J., Müller, J. A., & Trachsel, M. (2020). Ethical Issues in Online Psychotherapy: A Narrative Review. Frontiers in psychiatry, 10, 993. https://doi.org/10.3389/fpsyt.2019.00993
